skin grafting

The resident on call told me there should be a case at 7pm; so starting at 6:45 I went and sat on a bench near the OR control room, just to make sure that no doctor I knew went into the OR without me knowing it.

At 8pm, the surgeon returned from his daughter’s softball game, and we got the patient back. More than two months ago, he came in with necrotizing fasciitis, due to MRSA, which ate away his back. I’ve seen pictures of nec fasc (as it is familiarly known) on arms or legs. That’s almost acceptable, compared to the back. When I saw him tonight, everything was already debrided and cleaned away – down to muscle on most of his back, and around the side, and around the scapula. Ick. It hurt him so much to move, he asked the anesthesiologist to put him to sleep before we moved him to the table. Since he had a trach in, that was easy for her to do.

Somehow, I had the idea that skin grafting was a really meticulous, delicate operation. Wrong. The attending shaved the patient’s legs (to all the women’s amusement, at his clumsiness). Then the resident picked up what looked like a gigantic electric razor, and pushed it across about 12cm on one segment of his leg. She came away with a long, extremely thin piece of white skin. The part underneath didn’t bleed, so much as ooze slowly. They were doing a split-thickness skin graft, which means that you take the epidermis and part of the dermis. The dermis contains the blood vessels needed for healing, so both the donor site and the graft come away with part of the dermis. The donor site is thus able to regenerate in a few weeks, and the graft should be able to latch on to the blood vessels in the wound area.

Since he had such a huge area needing to be covered, they meshed the grafts. That is, they ran them through these rollers, which cut the piece of skin into a mesh, which could then be stretched out to cover a larger area. It looked incredibly delicate to me, and I was wondering whether I dared ask to touch any of it.

At that point, the attending handed me the razor, said to cut another strip, and walked off to the far side of the table. I was just barely more in awe of the attending than of applying the razor, so I didn’t drop it. (So many things I do because I’m more scared of angering the attendings than of just about anything else.) The resident showed me which buttons to push, and the angle to hold it at, and I incredibly managed to cut a large rectangle, apparently of the right depth, without gouging anywhere. Then, he showed me how to run it through the rollers, and then handed it to me to carry to the other side, and put – anywhere. I couldn’t believe it: here I am holding a skin graft!

So the resident kept cutting, and the attending and I arranged the meshed grafts, like some grotesque jigsaw puzzle, on his raw back, pulling and pushing and unrolling to stretch everything to the maximum. The attending was talking modern slang, joking around, laughing at my shyness, and my funny ideas about the delicacy of skin grafts. The last step was to put a thin dressing on, and staple it in place to keep the grafts from being dragged off as the patient is turned or moved. Seeing the attending’s example, I tried to ignore the uncomfortable idea of stapling onto raw muscle, and sprinkled them liberally all over the wound.